Are There New Significant Advances on Nurse-Driven Sedation Protocols?

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The article published in a recent issue of Pediatric Critical Care Medicine by Gaillard-Le Roux et al (1) about the implementation of a pediatric nurse-driven sedation protocol in a PICU endorses recent articles published on the subject (2, 3). A recently published Cochrane Systematic Review in adults report that there was no evidence of differences in duration of mechanical ventilation (MV) or hospital mortality after sedation protocols implementation (4). However, the article by Gaillard-Le Roux et al (1) raised some questions and concerns that we would like to debate.
The primary objective of the study was to access the length of MV after the implementation of a nurse-driven sedation protocol. In this case, a protocol for the tracheal extubation management of the patients is essential in our opinion. A guideline to wean the patient from MV and subsequent progression to tracheal extubation reduces the bias in this phase of the protocol.
We missed the use of dexmedetomidine in the protocol. In our setting, we are increasingly using this α2-adrenergic agonist sedative. Grant et al (5) report that the use of dexmedetomidine to facilitate extubation in children intolerant of an awake, intubated state may abbreviate ventilator weaning. Furthermore, it has demonstrated to be safe even in long-term use (6).
Another issue is that surgical patients represent a significant amount of patients in this study. However, the proportion of nurses to a patient is still 1:2, which is different from many other PICUs that keep that ratio on 1:1 in this kind of patient, conferring more quality and safety theoretically. Would the results be different in this case? We think that the commitment and training of the nurses are essential to the success of any protocol that is focused on nurses. How was that training? There was a leader in charge of the protocol application? Neunhoeffer et al (7) (2015) reported that “as more responsibility is given to PICU nurses, this might result in increased awareness and improvement of analgesia and sedation practice.” On the other hand, Curley et al (8) in a randomized trial conducted in 31 U.S. PICUs reported that among children undergoing MV for acute respiratory failure, “the use of a nurse-implemented, goal-directed sedation protocol compared with usual care did not reduce the duration of MV.”
This subject is of great interest, and there is still room for studies that could respond to so many questions.

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